OAR 411-054-0025 (5) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (a) Facility license. (b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility. (c) The current facility staffing plan. (d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable. (e) The Ombudsman Notification Poster. (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. (h) Other notices relevant to residents or visitors required by state or federal law. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all required postings were displayed in a routinely accessible and conspicuous location for residents and visitors. Findings include, but are not limited to: On 06/10/26 at 11:00 am, a tour of the facility was conducted with Staff 2 (Regional Quality Assurance Manager/RN). The following required postings were not observed to be posted: * Name of administrator or designee in charge (posted by shift); * Current facility staffing plan; and * LGBTQIA2S+ rights and protections. The need to ensure all required postings were displayed was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer), on 06/10/26 at 2 pm. They acknowledged the findings.

1. All required postings have been properly displayed in the community and visable for all residents and visitors. Required postings such as: Memory Care Administrator, Current Staffing Plan, and LGBTQIA2S+. 2. In-service has been done for all department heads to be aware and mindful of the condition and presence of required postings througout the community. Facility has posted the name of the administrator. The ABST is being reviewed weekly and/or as needed to ensure proper staffing is up to date and posted. LGBTQIA2S+ Nondiscrimination Notice has been displayed in the common areas and visable for all residents, staff, and visitors. 3. This will be an ongoing routine added to our daily and weekly QA audits to ensure we are consistent and in compliance. Daily community walk-thrus will include specific checks on all postings and weekly ABST audits to ensure accurate staffing. 4. All department heads including but not limited to the Executive Director, Assistant Executive Director and the Maintenance Director will be responsible for maintaining the integrity of all required postings. The Executive Director and/or Assistant Executive Director will be responsible for making sure the required postings are quickly updated in a timely manner as further updates may develop.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to immediately report suspected abuse to the local Department office for 1 of 1 sampled resident (#1) who experienced injuries during a resident-to-resident altercation. Findings include, but are not limited to: Resident 1 moved into the facility in 05/2024 with diagnoses including dementia with mood disturbance. Review of the resident’s clinical record and incident investigation noted Resident 1 was involved in a resident-to-resident physical altercation witnessed by staff on 06/05/26 at 3:00 pm. The facility investigation, dated 06/05/26, “caregiver statement” documented an unsampled resident approached Resident 1, “grabbed [her/him] by the face” and “had hands on [her/his] face telling [her/him] to “leave” and “get out.” The caregiver statements and facility investigation documented a “small red mark on left side of cheekbone” and “scratch on face” as injuries from the altercation. There was no documented evidence the 06/05/26 altercation was immediately reported to the local Department office as required. During an interview on 06/10/26 at 9:00 am, Staff 2 (Regional Quality Assurance Manager/RN) provided evidence the incident had been reported to the local Department office on 06/09/26 at 12:48 pm. The need to ensure incidents of suspected abuse were immediately reported to the local Department office was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:00 pm. They acknowledged the findings.

1. Self report for R#1 was completed on 6/9/26 however not within the 24hr window. A review of the last 30 days worth of occurrences will be conducted to verify self reporting as applicable. Re-education will be provided to MT/CG's on identifying, documenting, responding and reporting resident occurrences in a timely manner. 2. ED will provide training to newest Wellness Director, ALD, MCD and RN on the community's occurrence reporting process and the self report criteria and process to assure understanding. Resident occurrences will be reviewed during daily standup to assure completion of investigations and timely self reports as applicable. Routine audits of resident occurrence related documentation will take place to assure all occurrences are known. 3. Daily & Weekly 4. All Health Services management team: Executive Director, Health and Wellness Director, Memory Care Director (once one is hired), and the Registered Nurse.

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident needed or was receiving nursing services, and at least one other staff person who was familiar with or provided services to the resident, for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 and 2’s most recent service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team. The need to ensure service plans were developed with a Service Planning Team was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:50 pm. They acknowledged the findings.

1. The Service Plan binder was audited for signatures. All service plans that lack the appropriate amount of signatures by all service plan team members were set aside for review and signature. 2. Service plans will be created, implemented, and managed by service plan team. As service plans are updated, they will be reviewed by the team and signed in a timely manner. All parties on the service plan team will receive an invite for when it's time to update and review. 3. Service plans will be completed according to Service Plan Calendar. Audit of service plans will take place on a weekly basis to ensure they are updated and signed. 4. The health services team will be responsible for monitoring and auditing service plans. The health services team will consist of the Executive Director, Registered Nurse, Health and Wellness Director, and Memory Care Director (once one is hired).

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were monitored and weekly progress documented until resolution for 1 of 1 sampled resident (#1) with wounds. Findings include but are not limited to: Resident 1 was admitted to the facility in 05/2024 with diagnoses including dementia with mood disturbance. During the acuity interview on 06/08/26 at 10:00 am, staff stated Resident 1 had a wound on their left heel. A review of the resident’s 03/08/26 through 06/08/26 clinical record was completed, along with staff interviews. An alert charting note dated 05/05/26 documented the discovery of a wound: “resident noted with reddish discoloration to left heel.” Alert charting was noted until 05/10/26. Alert charting dated 05/10/26 noted, “Nurse to monitor until resolved”; however, there was no further documented monitoring of the wound after 05/10/26. In interview on 06/09/26 at 1:30 pm, Staff 13 (Med Aide) confirmed the discoloration was still present; however, there was no documented evidence of monitoring. The need to ensure changes of condition were monitored at least weekly until resolution was discussed with Staff 2 (Regional Quality Assurance Manager /RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:00 pm. They acknowledged the findings.

1. Resident #1's heel has been assessed and added to the wound log for weekly assessments until resolved. A review has been conducted to assure all active skin issues are known and present on the wound log. 2. Training will be provided to the new Wellness Director, ALD/MCD and Nurse on the change of condition and monitoring system for skin issues to assure understanding. ALD/MCD and Nurse will audit resident progress notes, occur reports and other resident care related documentation at least weekly to assure all known skin issues are present and weekly updates are current as applicable. Nurse will provide routine assessments of wounds/skin issues until they are resolved using the community wound log. 3. Weekly 4. ALD/MCD and Nurse with ED oversight.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#1) who experienced a significant change of condition. Findings include, but are not limited to: Resident 1 moved into the facility in 05/2024 with diagnoses including dementia with mood disturbance. During the survey, Resident 1 was observed eating independently, with some verbal cues from staff, and consumed approximately 50% of meals. The resident’s 03/08/26 through 06/08/26 clinical record and 01/10/26 through 06/08/26 weight records were reviewed, and staff were interviewed. b. The following weights were recorded by the facility: * 01/10/26: 130.5 pounds; * 02/10/26: 135.5 pounds; * 03/15/26: 116.0 pounds; (loss of 19.5 pounds in 33 days); * 04/10/26: 118.5 pounds; * 05/10/26: 118.5 pounds; and * 06/10/26: 119.0 pounds. Resident 1 experienced an unexplained 19.5 pound weight loss, or 14.3 % of his/her total body weight, in one month (from 02/10/26 to 03/15/26). The weight loss constituted a significant change of condition that required an RN assessment. There was no documented evidence the facility RN conducted an assessment until 04/10/26, 21 days after the weight loss was documented. Resident 1 was weighed during the survey, had regained 3 pounds of the 19.5 loss, and weighed 119 pounds on 06/10/26. The need to ensure significant changes of condition were assessed timely by the facility RN was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:00 pm. They acknowledged the findings.

1. Resident #1: weight assessment was completed but not within an acceptable time frame for the March 2026 weight variance. A review has been conducted of current weight variances to assure assessments have been completed. 2. Training has been provided to the new Wellness Director, ALD/MCD and Nurse of the community weight monitoring policy, timeliness of weight assessments and required weekly f/u per rules to assure understanding. ALD/MCD will assure monthly weights are completed and RN assessments are conducted in a timely manner in accordance with community policy. 3. Monthly 4. Wellness Director, ALD/MCD and Nurse with ED oversight. .

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols. Findings include, but are not limited to: a. On 06/08/26 during lunch service, a staff member was observed transporting uncovered lunch plates and beverages from the kitchenette to individual resident rooms. At 11:39 am the cart with three meals and multiple beverages was wheeled into an unsampled resident’s room. A few minutes later the staff member exited the room with the cart and proceeded to enter another unsampled resident’s room with the two remaining plates of food and beverages. The staff member was observed exiting this room and entering a third unsampled resident’s room. b. On 06/08/26 the survey team requested the name of the facility Infection Control Specialist and documentation of department-approved specialized training in infection prevention and control protocols. On 06/10/26, Staff 2 (Regional Quality Assurance Manager/RN) provided documentation that Staff 6 (ED) had completed the required four-hour infection prevention and control training on 06/09/26. The need to establish and maintain effective infection prevention and control protocols, including designating an individual to be the facility’s Infection Control Specialist, was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:50 pm. They acknowledged the findings.

1. We now have 3 Infection Prevention and Control specialists. The classes were taken and certificates obtained. Staff will be in-serviced about infection prevention focusing on cross contamination while delivering room trays for residents. 2. The expiration date for the certificates have been put on a calendar to ensure timely renewal. Training documents will be audited to ensure all staff have completed and comprehend the Infection Prevention online course through Relias. 3. Training records will be audited on a weekly basis for the next 30 days to ensure compliance. 4. The Assistant Executive Director will be responsible for auditing training records and ensuring all staff are up to date on the Infection Prevention course.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with restraining qualities was assessed by an RN, PT, or OT prior to use, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 2 of 2 sampled residents (#s 1 and 2) who used side rails. Findings include, but are not limited to: 1. Resident 2 was admitted to the MCC in 05/2026 with diagnoses including Lewy body dementia and Parkinson’s disease. During the acuity interview on 06/08/26, Resident 2 was identified as using a side rail. Observations of the resident’s room throughout the survey identified a half side rail on the side of the bed that was not against the wall. In an interview on 06/09/26 at 12:50 pm, Staff 19 (CG) reported that the rail was always placed in the up position when the resident was in bed, and that Resident 2 had been using the side rail since admission. Resident 2’s service plan available to caregivers, dated 05/04/26, documented that the resident did not use a side rail. On 06/09/26, the surveyor requested an assessment for the side rail and was provided with a “Supportive Device with Restraining Qualities Evaluation” dated 06/08/26. There was no documented evidence the facility RN, PT, or OT had conducted an assessment prior to 06/08/26, or that the facility had instructed caregivers on the correct use of and precautions related to the device. The need to ensure any device with potential restraining qualities was assessed prior to the use of the device, the facility had instructed caregivers on the correct use and precautions related to use of the device, and documentation of the use of the device was included in the resident service plan was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:50 pm. They acknowledged the findings. 2. Resident 1 was admitted to the MCC in 05/2024 with diagnoses including dementia with behavioral disturbance. Resident 1 was observed on 06/08/26 using a hospital bed with a side rail. In an interview on 06/09/26 10:30 am Staff 19 (CG) stated the side rail was placed in the up position whenever Resident 1 was in bed. Clinical record review from 03/08/26 through 06/08/26 showed no documented assessment by an RN, PT, or OT for Resident 1’s side rail. The current service plan, dated 05/20/26, noted Resident 1 did not use a side rail, and there was no documentation that direct care staff were instructed on the correct use of or precautions related to the side rails. On 04/23/26 at 4:20 pm, the need to ensure a device with restraining qualities was evaluated by a PT, OT, or RN prior to use, care planned, and staff were instructed on the correct use of and precautions related to the device was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:00 pm. They acknowledged the findings.

1. Resident #2: Restraint evaluation is complete and service plan updated with applicable information on the device in use. A walk through was conducted to assure all devices in use were known, evaluations current and service plans reflective of use. 2. Training was provided to Wellness Director, ALD/MCD and Nurse of community policy and state regulations for use of supportive/restraint devices to include timeliness of evaluations and information required to be on the resident service plan. Ongoing audits will be conducted to assure awareness of any new devices and that evaluations are current and timely and service plans accurate for use. 3. Weekly 4. Wellness Director, ALD/MCD and Nurse with ED oversight.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and recorded according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Upon survey’s entrance to the facility on 06/08/26, fire and life safety records for the past six months were requested. The facility lacked documented evidence unannounced fire drills were conducted and recorded at least every other month. On 06/10/26 at 11:30 am, Staff 6 (ED) confirmed the facility’s lack of documentation of fire drills. The need to ensure fire drills were conducted every other month and recorded according to the OFC was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer) on 06/10/26 at 2:50 pm. They acknowledged the findings.

1. Fire drills will be done every other month, and Fire Life Safety in-services and education will be done on alternating months. All staff will be mandated to attend and participate to ensure proper training and preparation for if evacuation is ever needed. 2. The Safety Committee team will put on their calendars days and times for upcoming fire drills and training. Community will follow closely the calendar to ensure quality drills and in-services are happening consistently and according to schedule. 3. The Fire Life and Safety binder will be audited and maintained on a monthly basis to ensure compliance. 4. Maintenance and Safety Committee will be responsible for making sure fire drills and education are taking place consistently and according to calendar.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to reinstruct residents at least annually. Findings include, but are not limited to: On 06/10/26, the surveyor requested documentation of Resident 2 being instructed on the required fire safety information within 24 hours of his/her admission, as well as documentation of the facility’s process for providing reinstruction to all residents annually. At 1:30 pm on 06/10/26, Staff 4 (Chief Operations Officer) reported that there was no documentation on either of these items. The need to ensure fire and life safety instruction was provided to residents upon admission and at least annually was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 on 06/10/26 at 2:50 pm. They acknowledged the findings.

Fire Life and Safety meeting for residents will be scheduled fo every 6 months. New residents will receive orientation within 24 hours of admittance to the community that will include instructions on the required fire safety information. 2. All new residents will attend an orientation within the first 24 hours of moving in to ensure comprehension about fire safety, emergency exits, and point of safety. Fire drills and in-services for residents will be put on a calendar to ensure compliance. 3. Fire drills and in-services will be done every 6 months. New residents will receive fire safety instructions within 24 hours of moving in. 4. Assistant Executive Director and Maintenance will be responsible for maintaining schedule, fire drills, and in-services for residents.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit. Findings include, but are not limited to: On 06/09/26 at 11:30 am, Staff 9 (Maintenance), Staff 1 (Regional Director of Health Services), and Staff 2 (Regional Quality Assurance Manager/RN) were shown the shared bathrooms in apartments 15 and 16 and confirmed the shared bathroom doors did not lock. Residents sharing the bathroom with a roommate could not lock the doors for privacy when using the bathroom. On 06/10/26 at 11:30 am, during the environment walk through with Staff 2, the need to ensure each individual had privacy in his or her own unit, including privacy when using bathrooms that were shared between roommate, was discussed. On 06/10/26 at 2 pm, the HCBS requirement for locking doors was discussed with Staff 2 (Regional Quality Assurance Manager/RN) and Staff 4 (Chief Operating Officer), they acknowledged the findings.

1. Bathroom locks will be installed to ensure privacy for residents that share a suite. Staff will be in-serviced to inform them of the rule and new locks on bathrooms. 2. Bathroom locks will be added to the environmental audits to ensure they are present and in good working order. 3. Montly audits will be done on all bathroom locks to ensure presence and good condition. 4. Maintenance will be responsible for the montly audits of bathroom door locks. Staff will monitor and report any issues to maintenance.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings (5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following: (f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections. (g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted. This Rule is not met as evidenced by: Based on observation and interview, the facility failed to ensure Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections, were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to: Refer to: C152.

1. All required postings have been printed, framed, and displayed in the community and visable to all residents and visitors. Staff will be in-serviced about the purpose of required postings and educated on how they can help maintain integrity of postings. 2. All staff in the community will be aware of required postings and alert maintenance if they discover any issues or absence of postings. 3. Daily audits to make sure postings are visable and in good condition will be added to the environmental QA. 4. Assistant Executive Director and Maintenance will be responsible for ensuring the required postings are visable and in good condition.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C152, C231, C295, C420, and C422.

1. PLEASE REFER TO C152, C231, C295, C420, AND C422. 2. PLEASE REFER TO C152, C231, C295, C420, AND C422. 3. PLEASE REFER TO C152, C231, C295, C420, AND C422. 4. PLEASE REFER TO C152, C231, C295, C420, AND C422.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C262, C270, C280, and C340.

1. PLEASE REFER TO C262, C270, C280, AND C340. 2.PLEASE REFER TO C262, C270, C280, AND C340. 3. PLEASE REFER TO C262, C270, C280, AND C340. 4. PLEASE REFER TO C262, C270, C280, AND C340.